Managing dental neglect
When dental neglect is suspected and is accompanied by signs of general neglect a child protection referral should be made as already discussed. However in cases where there is a lower level of concern and signs of apparently isolated dental neglect, it may be appropriate for the dental team to consider a tiered response. Three stages of intervention, implemented according to the level of concern, are described below:
Preventive dental team (single agency) response
Preventive multi-agency response
Child protection referral
This approach was developed for the first edition of Child protection and the dental team in 2006, from earlier local good practice guidance in use in Rotherham,30 having received the approval of a multi-agency team of critical readers. It was subsequently adopted by the British Society of Paediatric Dentistry in the society's first policy document on dental neglect.50
Stage 1. Preventive dental team management
This involves raising concerns with parents, offering support, setting targets, keeping record and monitoring progress. The initial focus should be on relief of pain accompanied by preventive care. In order to overcome problems of poor attendance, dental treatment planning should be realistic and achievable and negotiated with the family. The table below shows an example of how the dental team might put this into practice where resources permit. If concerns remain, management should progress to the next stage.
Example of a preventative single agency response to dental neglect: a team approach (applied to a 4-year-old child with caries who only attends when in pain)
Raise concerns with parents||
Explain clinical findings, the possible impact on the child, and why you are concerned||
Explain what changes are required||
Explain treatment needed and expectation of attendance|
Give advice on changes needed in diet, fluoride use and oral hygiene
Therapist, hygienist or dental nurse as appropriate
Consider giving free fluoride toothpaste and brush|
Offer the parent or carer a choice of appointment time
Listen for indications of a breakdown in communication, or parental worries about the planned treatment, and offer to discuss again or to arrange a second opinion if this is the case
All team members
Keep accurate records||
Keep accurate clinical records|
Keep accurate administrative records of appointments and attendance
Dentist and/or other team members|
Continue to liaise with parents/carers||
Keep up open communication with the parents and repeat advice, so that they know what is expected of them||
All team members|
Arrange a recall appointment||
If concern that child is suffering harm, involve other agencies or proceed to make a child protection referral
Consult other professionals who have contact with the child (e.g. health visitor, nursery nurse) and see if your concerns are shared
Take further action without delay if indicated
Much of this will be familiar to those who already employ a preventive approach to treatment planning for children. However ‘setting targets’ and ‘monitoring progress’ have been highlighted as actions that dental teams would do well to emphasise.51 If you have any doubts about the appropriateness of such action, you should discuss with an experienced colleague and proceed to
make a referral to children's social care (social services).
Stage 2. Preventive multi-agency management
This involves liaison with other professionals who are working with the family, such as the health visitor or school nurse, general medical practitioner or social worker, to see if concerns are shared and to clarify what further steps are needed. A child may be the subject of a
CAF (Common Assessment Framework) at this level. Children’s services should be aware of this but may not be directly involved. It should be checked whether the child is subject to a child protection plan (which replaced the child protection register). A joint plan of action should be agreed and documented, with a date specified for review.
sample letter to health visitors regarding children under-5 who fail to attend, to assist you in multi-agency working.
Stage 3. Child protection referral
If at any point the situation is found to be too complex or deteriorating and there is concern that the child is suffering significant harm, the dental team should not delay in making a child protection referral according to local procedures.
Illustrating good practice in:
early intervention to safeguard children
management of dental neglect
A family with four children aged 7, 4, 3 and 1 attended for a dental examination. The eldest had been a patient at the practice two years previously but then failed to complete a course of treatment. On this occasion all four children had dental caries and poor oral hygiene, the younger children presenting with more extensive caries at an earlier age than their older siblings.
At subsequent appointments it became apparent that all the children were consuming frequent sugar-containing snacks and drinks. The two youngest children were drinking juice from a bottle throughout the day and night. Advice was given on caries prevention. Their mother reported increasing difficulty coping with the children’s eating and sleeping habits and behaviour. She readily agreed to the dentist’s offer to contact their health visitor to see if any support and advice might be available.
The health visitor visited the family at home on several occasions over the next six months to give advice on various aspects of health and parenting. She put them in touch with local Sure Start services. The situation soon improved and there were no further concerns.
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Images reproduced with permission of Mrs J C Harris|
In the months that followed, the two younger children required dental extractions under general anaesthesia. A note was made that they remained at high risk of caries and would require regular preventive care. When they missed a subsequent recall appointment and no response was received to a letter offering a further appointment, the health visitor was informed by letter (download
sample letter) in accordance with practice policy. This prompted the family to phone for a further appointment and they now attend for regular dental care.